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� <br />FOR OFF�CE USE ONLY <br />AD�RESS <br />(1) 'BUIL'DING PERMIT FEE <br />(A) PLAN CHECK FEE <br />(2) PLUMBING � <br />(3) MECHANICAL <br />(4) STATE SURCHARGES <br />(A) BUILDING CODE <br />(B) ENERGY CODE <br />(5} DHIVEVNAY PERMIT <br />(6) WATER SERVICE TO BE PAID PRIOR TO BUILDING PERMIT ISSUANCE <br />(A) TO BE DET�RMINED BY BLDG. INSPECTOR _ ��� INCH <br />(B) EXIST. WATER SERVICE. APPLICATION NO. <br />(7) STATUS OF SEWER CHARGE�: <br />BOND DISTRICT FOOTAGE <br />N, S. E, W <br />SYSTEMS DEVELOPMENT <br />WATER <br />SEWER <br />TOTqL ORD. FEE <br />SEWER CONNECTION CHARGES <br />YEAR TRUNK <br />LATERAL <br />TOTAL CONNECTION CNARGES <br />SEWER PERMIT FEE <br />F� <br />$ __ /Oi/ , 7 � <br />$ — /'2(0-%5 <br />5� �3°a <br />- � �� � � ao�y.s � • <br />p�� <br />d/ <br />/� �!o <br />$ <br />$ / <br />$ �v <br />